Blog Post: Comments to the Washington Examiner

The Washington Examiners‘ Robert King had an article today about the ongoing single payer battle, “Sanders reignites fight over single-payer healthcare“.

The article notes that though some would contend that the debate over incrementalism vs. more fundamental reform is already behind us, “…single-payer advocates beg to differ.” In this case, I was the single-payer advocate doing the begging:

“The Affordable Care Act didn’t address a lot of the problems in the [healthcare] system,” said Adam Gaffney, a physician, writer and single-payer advocate. Gaffney said his views don’t represent any groups he is affiliated with.

Cost-sharing requirements such as co-pays and deductibles have increased, and more than 30 million Americans are underinsured, Gaffney said.

“Regardless of what happens in the coming general election, the Affordable Care Act will not have killed single payer,” he said.

Gaffney said he was disappointed that Clinton seems to be “closing the door on a single-payer program given that so many people support it.”

Available at:


Newsletter #1


Newsletters are retro and trendy.  In an effort to not feel left out I’ve started one too. You can signup here:

Given a paucity of current subscribers, I’ve decided to post the letter on this blog as well.  Here it goes …

This is the first of what I hope to be biweekly newsletters, which will combine what (if anything) I’ve written in the intervening period as well as some of the latest in health news/politics/policy (and other items of interest).

So this past week saw a rather vigorous exchange on everybody’s favorite topic (well, at least mine): single payer health insurance.  Hilary Clinton opened with a salvo about Sanders’ health care plan being a “risky deal,” as reported by the Washington Post, which would devolve responsibility for health insurance to state governors.  Chelsea Clinton one-upped this by describing Bernie Sanders’ single payer proposal as a rather frightening sounding scheme that might effectually “…strip millions and millions and millions of people off their health insurance,” as she was quoted by MSNBC.  Basically everybody agreed that this was nonsense.  Ezra Klein wrote about it here at Vox:

Hillary Clinton’s campaign has spent the past few days indulging its worst instincts. It blundered into a dumb attack on Bernie Sanders, but rather than back down it raised the stakes. The result has been a reminder, to liberals, of what they like about Sanders and mistrust about Clinton.

Well put.  I wrote a post (“Chelsea Clinton Grossly Misrepresents Single Payer“)  about the silliness of the Clintons’ charge, and also noted that Chelsea Clinton has little excuse not to have a handle on the issue given that she is something of a public health person (then again, so is Hillary Clinton).  Zaid Jilani of the Intercept also made the good point that, as the headline of his article puts it, “Hillary Clinton’s Single-Payer Pivot Greased By Millions in Industry Speech Fees.” Perhaps the best response was this tweet from the Bernie Sanders campaign, harkening back to an earlier era when HRC’s opinions on single payer were a bit different:


On the other hand, Matt Yglesias at Vox had a less helpful piece asserting, to some extent, that what really matters about single payer is lowering provider reimbursements, which might be done with or without single payer.  Indeed, implementing single payer without an across the board reduction in provider payments, he contends, would be very costly and not very useful.  I disagreed strongly with him in this post, “What’s wrong with Matt Yglesias’ Single Payer Analysis.” Now admittedly, I might be said to have something of a conflict of interest on the topic as a health care provider myself.  But that’s really beside the point: whether or not providers should be paid less is separate from the question of whether we should have a single payer system.  Single payer would have huge administrative efficiencies over our current fragmented mess of a system: it could save a great deal of money separate from the issue of provider reimbursement.  Fellow PNHPer Don McCanne had a more comprehensive take on his blog here.

In closing, consider having a look at a piece I wrote for The New Republic (online) about Sasha Issenberg’s forthcoming book, Outpatients: The Astonishing New World of Medical Tourism.  It’s a wacky world no doubt, and also a good book.  I more or less contend that medical tourism should be understood in the larger context of the corporatization of health care and a global retreat from a vision of universal public health care.

Blog Post: What’s wrong with Matt Yglesias’ Single Payer Analysis

Does single payer save money? Matt Yglesias had a piece in Vox today headlined “The single-payer debate we should be having,” in which he admits that Hillary Clinton’s recent anti-single payer (SP) attack is “questionable,” but contends that we’re missing the main point about SP: namely, that it saves money by reducing reimbursement to health care providers like physicians.

Such a move would be politically very difficult, he argues, and in any event we could very well cut payments without moving to SP – and save money all the same. It’s best to quote him at length:

Single-payer systems save money by squeezing health care providers — doctors, hospitals, and ultimately everyone who works for them — which would be very difficult to accomplish ex post facto. If the political consensus did exist for enacting large, across-the-board cuts in doctors’ fees and hospital charges, then there would be no need to shift to a single-payer system in order to accomplish the cuts. In the absence of such a consensus, the switch to single-payer actually wouldn’t save money, and the costs would become exorbitant.

Thus, he contends that “a single-payer structure is neither necessary nor sufficient” to reduce health expenditures in this fashion. He says a lot in this article, some of which is fair, but this specific point is incorrect.

In passing, Yglesias briefly mentions that SP would be administratively simpler, yielding some increased efficiencies. But this is entirely inadequate: reduced administrative expenditures would be a primary source of potential savings under SP. This may sound wonkish, but it’s a point of great importance in this very high-stakes debate.

There’s a whole literature about administrative inefficiencies of the US health care system, but I’d ask Yglesias to have a look at this paper by Jiwani et al., Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence, published in BMC Health Services Research in 2014 (note: two of the co-authors [DS and SW] are colleagues/collaborators on other projects). The paper provides an estimate for “billing and insurance-related” (BIR) costs for the US health care system, and compares it to Canada, which has a single-payer system.

The potential estimated efficiency savings are enormous. In comparison to the SP system in Canada, “added BIR costs” were estimated at $49 billion/year for physician practices, $54 billion/year for hospitals, and $69 billion/year for “other health service and supplies.” Using US Medicare as a benchmark, added BIR costs were estimated at $185 billion/year for private insurers and $18 billion/year for public insurers.   Depending on the exact assumptions used, the investigators produced a “plausible range for overall added BIR costs in the US of $254 – $507 billion in 2012…”

The implications of this are clear: the efficiencies of a SP system – which could reduce or eliminate the need for a whole range of administrative and billing activities at the level of insurance companies, hospitals, and doctors’ offices – could be a substantial contribution towards expanding coverage under SP. To quote the investigators:

Implementation of a simplified financing system offers the potential for substantial administrative savings, on the order of $375 billion annually, which could cover all of the uninsured and upgrade coverage for the tens of millions who are under-insured.

This might sound farfetched for those who are unfamiliar with the enormous administrative inefficiency of the US health care system. Hospitals, for example, currently tabulate complex patient-by-patient bills, sometimes for every service or supply utilized (and often chase down those with unpaid bills using debt collection agencies). Under SP, they could instead be paid “global budgets” to cover all operating expenses and all patients; the need for hospital billing departments would thereby shrivel. Physicians practices’ likewise must bill (and jostle with) an ever-changing roster of insurance plans, requiring significant staff and/or time.

In short, Yglesias’ analysis of the current SP debate almost entirely neglects how increased administrative simplicity could pay for a SP system that eliminated both uninsurance and underinsurance. Even if overall health care expenditures were unchanged at the end of the day, this would be quite a bargain.





Blog Post: Chelsea Clinton Grossly Misrepresents Single Payer

Chelsea Clinton isn’t just a political surrogate, she’s someone who purports to know something about public health. She is, after all, the Vice Chair of the Clinton Foundation, where – according to its website – she works on the organization’s multiple public health projects.  More to the point, she is an adjunct assistant professor in health policy and management at the Columbia Mailman School of Public Health, where she earned her Masters in Public Health degree.

Which makes her gross misrepresentation of Sanders’ health plan only that much more contemptible. “Sen. Sanders wants to dismantle Obamacare, dismantle the CHIP [Children’s Health Insurance] program, dismantle Medicare, and dismantle private insurance,” she was quoted as saying by MSNBC while on the campaign trail for her mother in New Hampshire. She continued (again as quoted by MSNBC): “I worry if we give Republicans Democratic permission to do that, we’ll go back to an era – before we had the Affordable Care Act – that would strip millions and millions and millions of people off their health insurance.”

This would be an absurd interpretation of Sanders’ single payer proposal for anybody, much less for someone with some background in health policy. It doesn’t seem to have been an off-the-cuff remark, however: it mirrors a somewhat similar comment made by Hillary Clinton the day before. As she was quoted by the Washington Post:

His plan would take Medicare and Medicaid and the Children’s Health Insurance Program and the Affordable Care Act health-care insurance and private employer health insurance and he would take that all together and send health insurance to the states, turning over your and my health insurance to governors.

Now I’m a single payer advocate, active in the organization Physicians for a National Health Program (though the views expressed in my articles and blog posts are mine only). If you don’t agree with the vision of a single payer program – whether because you think private insurers do a right proper job of delivering a right to health care or because your campaign receives generous funding from the pharmaceutical industry or whatever – so be it.

But don’t grossly misrepresent such a system by suggesting that Sanders would “dismantle Medicare,” as Chelsea Clinton did. Particularly not when the text of Sanders’ 2013 single payer bill states, “…the 113th Congress should enact a Medicare-for-All Single Payer Health Care System…” This bill is one of several single payer bills and proposals. Representative John Conyers’ single payer bill, H.R. 676, is in fact named the “Expanded & Improved Medicare For All Act.” To suggest that a system that would provide an improved Medicare program universally to the nation would somehow sneakily rob seniors of their Medicare coverage demonstrates a rather poor grasp of the issues (or something worse).

What both Clintons’ seem to be alluding to, as The Week’s typically on-point Ryan Cooper described earlier this week, is the fact that Sanders’ 2013 bill configures a single payer plan that would, to some extent, have a state-based administrative structure (though it would still be a federal plan and be implemented in every state). Cooper contends that there are some reasonable objections to such a structure, and that perhaps an entirely federal plan might well be superior.

Yet these are relatively minor details. To characterize Sanders’ single payer platform as some sort of dispersal of health care to the whim and fancy of each individual state is fantastically inaccurate. Sanders’ has proposed a fundamentally universal system: a national health program that would cover essentially everyone in every state. At that point, we wouldn’t need a separate Medicaid or Medicare program (or private insurer), which is the raison d’etre of “single payer.” Such a system would be far more just and equitable than what we have now, where – even with the Affordable Care Act largely intact – 32 million remain uninsured and another 31 million underinsured, among other failings.

Of course, such issues will never be a problem for Chelsea Clinton, primarily because she is part of a fabulously rich family. Indeed, as the Intercept’s Zaid Jilani described yesterday in a good piece entitled “Hillary Clinton’s Single-Payer Pivot Greased By Millions in Industry Speech Fees,” Hillary Clinton has raked in a cool $2.8 million in speaking fees in the past two years from the health care industry alone. Jilani also notes that Bill Clinton gave a speech (one presumes for a hefty fee) last year for America’s Health Insurance Plans, the main lobbying group for the health insurance industry. And Chelsea Clinton herself is already able to command $65,000 per college speaking gig, according to the Washington Post.

Like her parents, in other words, Chelsea Clinton is unlikely to go broke from a sky-high deductible or because she inadvertently went to an “out-of-network” doctor or hospital; she’ll never be forced to choose between filling a prescription and paying for rent. Nor should she – nor should anybody.

But obviously that’s no excuse for a campaign surrogate (much less an adjunct assistant professor of health policy and management) to so grossly mischaracterize a rather familiar health reform proposal, particularly not one that has the potential of improving – indeed saving – the lives of so many.